The most important advances in treatment in the last 25 years have been the use of methotrexate as a disease modifying anti-rheumatic drug (DMARD) and the use of biologic therapies to get this disease into remission.

Before discussing therapy, it is critical that a rapid, accurate diagnosis of RA be made as soon as possible. This is because the damage to both joints as well as internal organs may occur early in the course of illness.

Newer laboratory tests such as the anti-CCP as well as imaging techniques such as magnetic resonance imaging and diagnostic ultrasound have made the diagnosis easier.

A recent study has demonstrated that patients with shorter duration of disease and less severe disability are increasingly being treated with biologic therapies. (Soderlin MK, et al. (Ann Rheumatic Dis. 2008; 67:37-42).

Why is this approach a good one?

Another recent study has demonstrated that TNF-inhibitors, the first line biologic therapies used disrupt the architecture of structures in the lymph system called germinal centers, which are a type of training ground for immune cells.

Normally, the structures help when the host is ill from an infection. The structures swiftly churn out lots of B cells, which the body uses to destroy invaders.

In healthy people, once an infection is beaten off, the germinal centers fade away. But in people with a chronic autoimmune disease like rheumatoid arthritis, these germinal centers continue to train immune cells to become autoimmune attackers.

A team of researchers from the University of Rochester found that anti-TNF compounds inhibit the function and organization of cells known as follicular dendritic cells, which help form the germinal centers.

Follicular dendritic cells have long tentacles that lock onto B cells and hold them in place during their training.

The researchers found that the anti-TNF medication dropped the percentage of B cells in the lymph tissue by about 40 percent in patients. They also found that arthritis patients who received anti-TNF therapy had about one-quarter the number of germinal centers as other arthritis patients. The germinal centers that did exist in patients were smaller and less organized.

TNF, a chemical messenger that stimulates the immune system, is an important trigger for diseases like rheumatoid arthritis. In fact, TNF inhibitors such as Enbrel, Humira, and Remicade have been extremely effective in inducing remission in most patients with RA.

More recently, a drug known as rituximab that targets B cells was approved in 2006 to treat rheumatoid arthritis. The effectiveness of that drug against rheumatoid arthritis supports the findings of the Rochester team and shows how both TNF inhibitors as well as B-cell therapies may have complementary roles in treating RA.

The upshot of the recent research is that:

• RA needs to be diagnosed early

• It needs to be treated aggressively by a well-trained rheumatologist

• No one drug will be effective for every patient and that different approaches may be required. That is why an expert needs to be consulted.